Quality Enhancement Director
Quality Enhancement Director
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$ 60000 - 65000
1 Vacancy
Job Description
Job Details
Description
CTF Illinois is seeking a motivated organized and detail oriented professional to join our team as a Quality Enhancement Director. If you have an eye for detail are a selfstarter with strong organizational skills and have previous experience working with individuals with developmental disabilities we would love to talk to you! As the Quality Enhancement Director you will be responsible for continuous improvement and ongoing quality monitoring of agency programs and services ensuring compliance with governmental regulation and accreditation requirements and acting as a resource for staff and other stakeholders. This includes establishing performance metrics analyzing data identifying areas for improvement and implementing strategies to enhance service delivery and client outcomes.
This position will be based out of Champaign IL but will require travel to all CTF Illinois locations (Olney Lincoln Mattoon Charleston and South Suburbs of Chicago).
Primary Duties and Responsibilities:
Quality Assurance
- Implement and maintain a comprehensive quality assurance system to ensure agency follows policies procedures and standards within all services and sites including: sites charting funds and medical compliance
- Ensure QA completion compliance by assigned QA staff
- Monitor analyze report and communicate to management monthly quality assurance results and ongoing trend analysis to determine areas that need observation and review of current practices.
- Provide leadership and training to agency assigned QA staff
- Create and implement standard QA measures and train accordingly
- Review all submitted QA documents and monitor for applicable follow up and plans of correction
- Conduct assigned QAs including site chart medical file and financial reviews monthly across the state
- Identify potential areas of compliance vulnerability and risk; work with operational departments to develop/implement revised policy and procedures
- Assists in the preparation or required programmatic monthly quarterly and annual meetings and reports for perspective current funding sources and accreditation.
- Develop collect and maintain a database that tracks annual completion dates for Implementation Strategy HRST Annual Health Assessment and other assessment tools compliance
- Employ and oversee a person who receives services at CTF as a member of the QA team who conducts QA reviews
- Implement person supported feedback as part of the QA system
- Coordinate and lead monthly Basic Assurances and Quality Enhancement (BAQE) meetings. Ensure all department reports are completed track data and maintain and communicate the ongoing recommendations and associated tasks list.
- Conduct staff and stakeholder surveys
- Analyze data and present results to stakeholders.
Compliance
- Ensure total agency compliance with all relevant federal state and local regulations related to quality and service delivery including but not limited to Illinois Department of Human Services and the following agencies and waivers
- Rule 115 CILA
- Rule 116 Administration of Medication in Community Settings
- Rule 119 CDS
- Bureau of Quality Management (BQM)
- Bureau of Accreditation Licensure and Certification (BALC)
- Critical Incident Reporting Analysis system (CIRAS)
- Home and Community Based Waiver
- LIGAS
- Serve as the agency liaison for all quality audits from the Illinois Department of Human Services.
- Coordinate interviews and site tours
- Collect organize and ensure reports match requested agency documents for survey submission
- In coordination with the Vice Presidents develop and submit any necessary plan of corrections
- Ensure plan of corrections trainings and documents are completed and filed
- Communicate survey results with agency
- Act as an independent reviewer to ensure that compliance concerns and issues of litigation or possible litigation are being appropriately evaluated investigated processed and resolved.
- Act as an independent internal investigator reviewing stakeholder complaints including rights violations accessibility issues and reports of confidentiality and HIPAA concerns.
Accreditation
Oversees and coordinates all activities to maintain CQL accreditation status:
- Be the liaison between CQL and agency
- Provide regular agency training on CQL standards and updates
- Coordinate Personal Outcomes Measures (POM) activity; trainings reporting and interviews
- Conduct regular POM interviews
- Conduct quarterly focus groups
- Maintain CQL database and portal
- Responsible for implementation and maintenance of CTF CQL plan of action
- Collect data on various metrics used to validate positive services including tracking: volunteers vacations outcomes met community connections
- Responsible for completing and submitting Basic Assurance and Shared Value report to CQL
OIG Liaison
- Be certified in OIG investigations
- Be a contact between OIG investigators and CTF ILLINOIS
- Schedule all necessary interviews and collect required documents from OIG requests for OIG investigators and agency files
- Organize follow up and respond to alleged violations of rules regulations policies and procedures
- Maintain a database of all OIG allegations information and findings and prepare monthly quarterly and annual reports for necessary meetings that analyze trends
Secondary Duties and Responsibilities:
- Maintains knowledge of required regulatory standards
- Keeps abreast of current trends in the filed as related to best practices that pertain to the populations served
- Serve on internal or external committees as assigned.
- Attendance to trade association meetings and conferences at the request of the CEO
- Other duties as assigned.
We offer:
- Pay Rate: $60000 $65000 annually depending on education and experience
- Health benefits and optional visions dental critical illness and accident insurance for fulltime employees
- Company paid short and long term disability
- Company paid life insurance for all fulltime employees
- Vacation and paid sick leave for all employees
- 401k with company matching
CTF Illinois is dedicated to empowering adults with developmental and intellectual disabilities to LIVE. WORK. ADVOCATE. Our success is measured in the number of lives we touch with the quality programs and services we provide. These personcentered programs are fueled by our dedicated staff caring volunteers and generous donors. CTF Illinois offers a wide range of communitybased programs and services striving to meet the needs and choices of each person we serve. We support people and their families by providing personalized planning and various resources to assist them in creating their lifelong journey.
Qualifications
Required Experience Education and/or Training:
- Bachelors Degree
- 5 Years Experience in disability field
- Willingness to travel to all CTF locations
- Valid drivers license and acceptable driving record
- Strong Microsoft Office skills; including but not limited to EXCEL and Presentation software
- Strong organizational skills coupled with excellent oral and written communication skills
Additional Experience Education and/or Training Preferred:
- Paycom skills
- CQL certified POM trainer
- Demonstrates considerable initiative selfdirectness resourcefulness and a firm commitment to CTF ILLINOIS values
Required Experience:
Director
Employment Type
Full-Time
